Leveraging mobile technologies to promote maternal and newborn health

Leveraging Mobile
Technologies to Promote
Maternal & Newborn Health:
The Current Landscape & Opportunities for
Advancement in Low-Resource Settings
The Center for Innovation & Technology in Public Health
Public Health Institute | Oakland, California

TOC
Leveraging Mobile Technologies in Maternal and Newborn Hea lth
Table of Contents
ACKNOWLEDGEMENTS……………………………………………………………………………………………… 4

EXECUTIVE SUMMARY……………………………………………………………………………………………… 5

INTRODUCTION……………………………………………………………………………………………………… 7

MATERNAL AND NEWBORN HEALTH FRAMEWORKS…………………………………………………………… 9

MOBILE HEALTH IN MATERNAL AND NEWBORN HEALTH…………………………………………………… 13
Stimulating Demand Among Pregnant Women and New Mothers.................................................. 14
Strengthening Human Resource Capacity......................................................................................... 19
Transforming Health System Capacity................................................................................................ 22

OPPORTUNITIES FOR mHEALTH IN MATERNAL AND NEWBORN HEALTH............................................ 26

ADVANCING MOBILE HEALTH IN MATERNAL AND NEWBORN HEALTH................................................. 27
Technology, Design, and Implementation........................................................................................... 29
Scaling and Sustaining......................................................................................................................... 30
Public Policy........................................................................................................................................... 30

CONCLUSION............................................................................................................................................. 32

REFERENCES............................................................................................................................................. 34

3

Acknowledgements

ACKNOWLEDGEMENTS
The authors would like to extend the deepest appreciation and regards to the many resources who

have helped inform the preparation and writing of this report. Many thanks go to Neal Lesh (Dimagi),
Eric Blantz (Inveneo), Brendan Smith (Vital Wave Consulting, Inc.), Pamela Riley (Abt Associates), Erin
Sines (MacArthur Foundation), Sandhya Rao (USAID, Office of Health, Infectious Diseases and Nutrition
at USAID), James Bon Tempo (Jhpiego), Catharine Taylor (PATH), Kiersten Israel-Ballard (PATH), Anton
Luchitsky (PATH), Peggy D’Adamo (USAID, Office of Population and Reproductive Health), Rose Reis
and Trevor Lewis (Center for Health Market Innovations), Heather Vahdat and Kelly L’Engle (FHI 360),
Patricia Mechael (mHealth Alliance, UN Foundation), Jaspal Sandhu (Gobee Group), Kelly Kiesling
(The mHealth Working Group), Stan Kachnowski (Mailman School of Public Health at Columbia
University), Katherine de Tolly (Cell-Life), Trina DasGupta (GSMA), Craig Friedrichs (GSMA), Kyla Reid
(GSMA), Alice Newton (Government Digital Service), Mojca Cargo (GSMA), Toni Eliasz (World Bank),
Jody Ranck (Consultant at IntraHealth International), Kate Cummings (Ushahidi), Rafael Anta (Inter-
American Development Bank), Bas Hoefman (Text to Change), Richard Bartlett (International Partnership
for Innovative Healthcare Delivery), Michael Syson (Ateneo de Manila University in Philippines), Juan
Rodriguez (Voxiva), Patricia J. Garcia (Universidad Peruana Cayetano Heredia in Peru), Walter Curioso
(Universidad Peruana Cayetano Heredia in Peru), and Rodrigo Saucedo Martínez (Instituto Carlos Slim de
la Salud of Mexico). We have drawn heavily from the practices, experiences, and contributions of these
individuals and their organizations to characterize the scale and scope of mHealth activity in maternal
and newborn health. This report would not have been possible without their sharing best practices,
recommendations, and learned lessons in relation to mHealth intervention design, implementation, and
evaluation, and the potential opportunities and levers for successfully advancing mHealth interventions at
scale and on a sustained basis. Our many thanks also go to Ada Kwan, Cathryn Meurn, Jennifer Potts,
Francis Gonzales, and Madhura Bhat for their help and support in the production of this report.

Most importantly, we would like to express our appreciation to the mHealth Alliance, hosted by the
UN Foundation. Without their leadership, support, and its commitment to advancing the role of mobile
technology in global health and investment in supporting mHealth practices in maternal and newborn
health, this report would not have been possible. It is our utmost desire that the product of our efforts
will go forward to inform the strategic use and implementation of mHealth to improve access to care
for pregnant women, mothers, and newborns so that reductions in maternal and newborn mortality –
achievable with existing technologies of today – can happen without further delay.

4

Executive Summary
EXECUTIVE SUMMARY
Every year, approximately 350,000 women die worldwide as a direct result of pregnancy and childbirth,

and for each woman who dies, approximately 20 others suffer from pregnancy-related consequences.1
Additionally, three million babies die every year before they are a month old, and a similar number are
stillborn.2, 3 When stillbirths are included, about half of all 7.5 million deaths in children under age five occur
before the end of the neonatal period, or the first 28 days of life, and without a reduction in the number of
neonatal deaths, a dent cannot be made in under-five mortality rates.4 With over six billion mobile phone
subscriptions spread across a world population of over seven billion, mobile technologies are rapidly
penetrating even the most remote corners of the world.5 For women and newborns in many low- and
middle-income countries (LMICs), the rapid expansion of mobile technology infrastructure presents an
unprecedented opportunity to increase access to health care and save lives that are lost from preventable
and avoidable conditions.

Objective
The objective of this report is twofold:
(1) to describe the current state of mHealth intervention design, implementation, and evaluation that can be
leveraged to improve maternal and newborn health globally and
(2) to identify ways to strategically advance mHealth in maternal and newborn care, as well as strategies for
scaling up interventions.

Methodology
This report prioritized information from 13 LMICs in Asia, Latin America, and Africa: Bangladesh, India, the
Philippines, Brazil, Mexico, Peru, Ghana, Kenya, Liberia, the Republic of South Africa, Rwanda, Tanzania,
and Uganda. A total of 70 projects related to maternal and newborn health (MNH) and 160 projects in other
health areas were identified. Key informant interviews were conducted with experts in health, technology,
and public policy, as well as those involved in the development and implementation of mHealth programs
worldwide. Additionally, this report was informed by a review of published information and by contacting
sponsoring organizations.

Findings
In MNH, combining mobile technologies with existing health system resources offers significant potential
to provide women and newborns with adequate and appropriate care through interventions that stimulate
demand for available services, promote improved access, and lead to efficiencies in care delivery and
management practices. As with other application areas of mHealth, MNH interventions face significant
barriers at technical, social, and economic levels.

Conclusions
The ability to conduct rigorous evaluation and provide evidence of demonstrable impact is the crucial catalyst
that will advance policy and investment in the field and lead to the successful scaling and sustainability of
mHealth interventions. As evidence accrues, policy makers will be able to push forward supportive national
policy for information and communications technologies in health care, which will promote an enabling
environment where the potential of mHealth can best be realized.

5

To achieve the MDGs and to
maintain better MNH beyond
2015, we must critically
examine new ways of using
existing resources

Introduction Leveraging Mobile Technologies in Maternal and Newborn Hea lth
INTRODUCTION to deliver these already proven interventions
Every year, approximately 350,000 women at scale to reach the mothers and newborns
die worldwide as a direct result of pregnancy who need them most.
and childbirth, and for each woman who dies,
approximately 20 others suffer from pregnancy- A closer look at global maternal and newborn
related consequences.1 Additionally, three million mortality trends shows that half of maternal deaths
babies die every year before they are a month old, occur in sub-Saharan Africa and a third occur in
and a similar number are stillborn.2, 3 When stillbirths South Asia with India contributing to 22 percent of
are included, about half of all 7.5 million deaths deaths with similar patterns existing for neonatal
in children under age five occur before the end of mortality.1,7 Challenges in getting effective solutions
the neonatal period, or the first 28 days of life, and to mothers and newborns who are most at-risk can
without a reduction in the number of neonatal deaths, be overcome by delivering proven interventions with
a dent cannot be made in under-five mortality rates.4 better coverage and quality particularly in Africa and
South Asia. Factors that hinder adequate health
Although the majority of these deaths and care from reaching the women and newborns
debilitating illnesses and injuries are preventable who are most at risk include distance to resources,
and avoidable (See Figure 1), reducing the under- severe shortages of trained health professionals,
five mortality rate and the maternal mortality ratio and lack of investment in public health. To achieve
has seen slow progress.6 Placed on the global the MDGs and to maintain better MNH beyond
agenda as Millennium Development Goals (MDGs) 2015, we must critically examine new ways of using
4 and 5, respectively, the global health community existing resources in regions where improvements
has determined what is effective at reducing the need to be made.
number of deaths, and now must focus on how

DEATHS OF CHILDREN UNDER FIVE MATERNAL DEATHS
Embolism 1%
Diarrhoea 14% Preterm 12% Sepsis 8% Haemorrhage 35%

Pneumonia 14% Asphyxia 9% Abortion 9%

Sepsis 5% Other direct 11%

Other
Other neonatal 5%
infections 9%
Pneumonia, Indirect 18%
neonatal 4%
Malaria 8%
Congenital 3%
Non-communicable
diseases 4% AIDS 2% Tetanus 1% Hypertension 18%

Injury 3% Pertussis 2% Diarrhoea,
neonatal 1%
Meningitis 2%

Measles 1%
CHILDREN 59% NEWBORNS 41%

Figure 1. Causes of deaths in children under five years of age and maternal deaths (Source: Global Campaign for the Health
Millennium Development Goals, 2011).

7

Introduction Leveraging Mobile Technologies in Maternal and Newborn Hea lth

With over six billion mobile phone subscriptions facilities with point-of-care decision support tools to
spread across a world population of over seven maintain existing standards and augment existing
billion, mobile technologies are rapidly penetrating protocols that have been proven to be effective in
even the most remote corners of the world.5 For case management.
women and newborns in many low- and middle-
income countries (LMICs), the rapid expansion At this time, mHealth applications in the MNH
of mobile technology infrastructure presents an field are in the formative stage, and existing
unprecedented opportunity to increase access to evidence for effectiveness and impact is new, but
health care and save lives, but how exactly can we rapidly evolving. This report aims (1) to describe
leverage the power of mobile technology to save the current state of mHealth intervention design,
the lives of women and newborns? implementation, and evaluation that can be
leveraged to improve MNH globally, and (2) to
Through mobile health (mHealth), or the use of identify ways to strategically advance and scale
wireless information and communication devices up mHealth in maternal and newborn care so
(e.g. mobile phones and smartphones) and mobile that opportunities afforded by mobile phones and
phone networks for health, not only can frontline networks can reach their full potential. This report
health workers carry tools loaded with protocols, will first provide frameworks currently used in the
but captured data can also flow through a health field of MNH, which will help provide a structure
system in real-time and deliver critical information to for general mHealth strategies and those that
support women’s and providers’ needs in a timely have been particularly implemented to improve
and efficient manner. Additionally, combining mobile MNH outcomes. Detail is then provided on how
technologies with existing health system resources mHealth can stimulate demand for services among
offers opportunities in stimulating demand for pregnant women and new mothers, strengthen
available services and expanding access to effective human resource capacity, and transform health
and already existing programs through growing system capacity. The report then summarizes
mobile phone networks, both of which can lead the opportunities that mHealth can leverage to
to higher levels of efficiency in service delivery, reduce mortality rates, as well as suggestions for
supervision, and management practices. strategically advancing the space.
To build from the accrued knowledge of global MNH,
In particular, for MNH, mHealth can support and a quick review of existing frameworks will help
strengthen existing efforts along the continuum of facilitate the integration of mHealth. This section will
care, as well as offer innovative solutions, such as describe two frameworks used in the field of MNH:
providing women with MNH-related information the maternal-newborn continuum of care and the
services by phone, in addition to providing Three Delays Model.
community-based health workers and health

8

METERN AL A ND
MATERNAL AND NEWBORN In reality, along the continuum of care, significant
HEALTH FRAMEWORKS variation persists in the levels of coverage, and
First, the maternal-newborn continuum of care because mHealth can provide solutions to improve

NEWBORN
ranges from pre-pregnancy and extends into access and extend reach of health efforts, it will be

HEA
pregnancy, labor and delivery, and postpartum or important to acknowledge these relations when
selecting and integrating appropriate strategies.

LTH FRA
postnatal care, and it naturally includes child health;
however, this report will focus primarily on the Figure 3 highlights the status in 2010 of coverage
MNH section of the continuum. The purpose of the estimates of evidence-based interventions related
continuum of care is to map the specific moments to maternal, newborn, and child health in 68 MDG
along the continuum where proven interventions countdown countries.8 The high rate of maternal

MEWORKS
ought to be delivered (See Figure 2). An analysis and newborn mortality in many low-resource
of ‘coverage gap’ measures, which represents the settings also reflects inequities in access to medical

percentage of a target population not receiving services because of the geographic and economic
critical services, indicated that the greatest imbalances that exist between rural and urban
inequities in services fall into the categories of populations and the rich and poor. Poor women
maternal and newborn care and family planning. and their infants living in rural areas have a higher
risk of poor pregnancy outcomes as a result of
barriers to accessing timely and adequate care
and limited preventive measures and treatments.
For example, only one in three rural women in
developing countries receive the recommended
care during pregnancy.b

PRE- PREGNANCY DELIVERY POSTPARTUM POSTNATAL
PREGNANCY

Family Family Skilled Emergency Postpartum/post natal
Facility Planning Planning attendance obstetric care for Mother and
at birth care Baby and IMNCI

PMTCT
Community Family Health education skilled attendance at birth Postpartum/post natal care for Mother and
Planning during pregnancy Baby, Identifying/referring newborn illness
birth planning

Figure 2. Maternal-newborn continuum of care (Source: mHealth Alliancea , Credit: UNICEF)

a. Maternal-Newborn mHealth Initiative. Retrieved on March 25, 2012 previously available on the web page:
mhealthalliance.org/content/maternal-newborn-mhealth-initiative-mmii
b. 2015 Millennium Development Goals: Retrieved on March 25, 2012 from: http://www.un.org/millenniumgoals/

9

METERN AL A ND

Number of Countdown countries adopting policy 60

50
46
NEWBORN

43
41
HEA

40
LTH FRA

30 29 29
26
22
20
MEWORKS

10

1
0
Community
International Maternity Speciﬁc Midwives IMCI treatment of New ORS Costed
Code of protection in notiﬁcation authorised adapted pneumonia formula implementation
Marketing accordance of maternal to administer to cover and zinc for plan(s) for
of Breastmilk with ILO deaths core set of neonates management maternal,
Substitutes Convention lifesaving aged 0–1 of diarrhoea newborn, and
enacted 183 interventions weeks child health
available

Figure 3. Coverage estimates from 2010 for evidence-based policies related to maternal, newborn, and child health
in 68 countdown countries. ILO=International Labour Organisation; IMCI=Integrated Management of
Childhood Illness; ORS=oral rehydration solution. (Source: Bhutta et al., 2010).

Median coverage for 68 priority countries*
90

80

70
Mortality risk
for children
60

50

40

30 Mortality
risk for
mothers
20

10

0
ANC coverage Institutional Delivery** Postnatal Care Breastfeeding DPT3 Vaccination

*Data compiled for 68 priority countries for the 2010 Countdown Report Sources: Coverage data; Countdown to 2011, decade report (2010). Data for mortality distribution
** Births occuring in the health facilities based on 1) for mothers; LI, XF, IJOG, 1996; for children; DHS survey data where available for 51
selected countries.

Figure 4. Mortality Risk for Mothers and Children Along the Continuum of Care
(Source: Global Campaign for the Health Millennium Development Goals, 2011).

10

METERN AL A ND
NEWBORN
HEA
FACTORS AFFECTING
PHASES OF DELAY
UTILIZATION AND OUTCOME

LTH FRA
Socioeconomic/Cultural Factors Phase I: Deciding to
Seek Care

MEWORKS
Accessibility of Facilities Phase II: Identifying and
Reaching Medical Facility

Phase III: Receiving Adequate
Quality of Care
and Appropriate Treatment

Figure 5. Three Delays Model for maternal mortality (Source: Thaddeus and Maine, 1994).9

Notably, the onset of labor marks the beginning of the need to have effective emergency responses.
another high-risk period that continues through the One model that frames the challenges of improving
immediate 48 hours after birth. Figure 4 highlights maternal mortality is the Three Delays Model,
the mortality risk for mothers and children along the which proposes that pregnancy-related mortality is
continuum of care. Expanding access to prenatal overwhelmingly due to delays in the decision to seek
care, family planning resources, proper nutrition care, access to the appropriate level of care, and
options, and postnatal care is important; however, receipt of the appropriate treatment and professional
around the onset of labor, 150,000 maternal deaths, care upon arrival at the health facility (See Figure 5).
1.6 million neonatal deaths, and 1.2 million stillbirths The maternal-newborn continuum of care provides
occur each year.c Almost all of the deaths occurring a general overview of what health systems can do
during this high-risk period take place in LMICs. In to assure that appropriate services are available
sub-Saharan Africa and South Asia, which together to mothers and newborns, but when designing
accounted for 87 percent of global maternal deaths effective interventions, it is equally important to keep
in 2008, less than half the women deliver in hospitals. in mind factors on the population side that may
Optimizing birth outcomes in these countries requires prevent the usage of services, regardless of whether
strengthening human resource and health system they are delivered with high quality or not. In this
capacities during this acute high-risk period, and report, ways mHealth can be integrated to reduce
encouraging women to deliver in well-equipped and these delays are described using this framework.
staffed institutional care settings, while addressing

c. Saving Lives at Birth: A Grand Challenge for Development (http://www.savinglivesatbirth.net)

11

Expanding mobile phone
penetration and network
coverage can remove
traditional geographic
and economic barriers
to health care

MOBILE
HEA
LTH IN MA
MOBILE HEALTH IN MATERNAL or health status reports; requests for self-reported
AND NEWBORN HEALTH data, encouragement or motivation to sustain
The rise in mHealth solutions to improve health a positive behavior (and the reverse, to reduce

TERN AL A ND
outcomes is largely attributable to the ubiquity of a negative one); and education and information
mobile phones as well as the convenience, user resources to improve self-efficacy. A systematic
friendliness, and relatively low cost of mHealth review of the literature on behavior change and
applications. Expanding mobile phone penetration clinical outcomes from disease management
and network coverage can remove traditional and prevention services delivered through text
geographic and economic barriers to health care, messaging found significant results in eight of nine

NEWBORN
particularly in emergency situations that can be studies that support text messaging as a tool for

HEA
life threatening, as is often the case for MNH. To behavior change.11 However, this review, much like
the other published evidence to date, reflects small-

LTH
provide the context to discuss the existing and
potential role of mHealth in MNH, a review of scale projects in high-income countries, and thus
mHealth across 13 LMICs was conducted. Lessons limits their relevance to many LMIC settings.

learned were drawn not only in MNH but from all
mHealth efforts. Figure 6 provides an overview of mHealth services
for MNH in LMICs organized by three categories
mHealth is fairly new with a rapidly developing reflecting responses to each of the delays in the
evidence base that suggests encouraging progress. Three Delays Model: stimulating demand among
In general, mHealth interventions fall primarily pregnant women and mothers, strengthening
into two categories: (1) those directed toward human resource capacity, and transforming health
improving the provision of health services where the system capacity. These three categories are further
predominant focus is at the health system level, and explored in more detail below.
(2) those directed toward the recipients of health
services where client-focused services can involve
sending health information or reminders to improve
treatment compliance or attend appointments.10
In the former, target applications make use of
mobile phone features for real-time or actionable
information for data collection, surveillance, supply
chain management, and point-of-care support
applications. In the latter, client-focused services
emphasize the promotion or reinforcement
of positive health behaviors and the use of
recommended health services, and mobile finance
services that facilitate savings toward the cost of
recommended health products and services.
With regard to the type of mobile phone features
utilized, recent evaluations of mHealth programs
indicate a potential to broadly support patient self-
management through text-message-based cues,
reminders, and prompts to schedule or confirm
an appointment; notifications for laboratory results

13

MOBILE
HEA
LTH IN MA

• Information services that increase awareness of health issues and available resources
Stimulating demand • Patient communication services that connect women to peer networks or local expert resources
among pregnant
TERN AL A ND

women and mothers
• Patient-support services for the management of health issues impacting health outcomes
• Financial services that remove barriers to access and utilization of available care services

• Services that support patient tracking and management at the community level
• Services that support risk screening, referral and rmote consultation
• Services that provide the point-of-care decision support to improve compliance with
recommended care guidelines
NEWBORN

Strengthening human
resource capacity
• Services that strengthen or improve human resource management processes
HEA

• Services that equip community-based health worker cadres with mobile tools and extending the
LTH

physical space of health facility coverage into the households and community
• Services that transform the submission of monitoring and evaluation indicator reports from
paper-based to electronic or mobile-based, which can then enhance not only monitoring,
Transforming health surveillance, and detection, but also accountability
system capacity • Services that improve governance, supply chain, and clinical process efficiencies

Figure 6. mHealth services in MNH.

Stimulating Demand Among increase women’s awareness of MNH issues and
Pregnant Women and New promote behavior change in their utilization of
Mothers related care services; directly connect women to
Reasons that may delay a woman’s decision to expert resources such as skilled birth attendants
seek care are many and the result of a confluence at health clinics; provide complementary patient
of factors. These include a lack of knowledge support services for the prevention and treatment of
about health services and complications during health issues contributing to maternal and newborn
pregnancy and how these complications are mortality; and/or offer mobile financial services
managed, as well as geographic, economic, and which either remove financial barriers to care or
socio-cultural barriers. In certain societies, the lower directly encourage women to save toward delivery
status of women is a barrier to their ability to make and post-natal care.
independent decisions regarding their own care.
Other barriers include the lack of financial resources Because pregnant women can also be reached
to pay for hospital services and to purchase through extended caretakers in their communities,
medications; beliefs and practices surrounding mHealth interventions in this category also target
childbirth and delivery, nutrition, and education; and family members of pregnant women, such as
a lack of trust in health systems. a spouse or mother, or influential community
members. Targeting these individuals can facilitate
mHealth solutions that have been designed to the knowledge transfer of appropriate care, as
influence a woman’s decision to seek care can well as encourage expectant mothers to seek
address the problem from several perspectives. services. mHealth can also create peer networks of
Table 1 summarizes mHealth strategies for pregnant women or partner first-time mothers with
supporting pregnant women and encouraging them experienced mothers for support.
to seek medical care. In this regard, strategies
have been standalone or integrated and aim to:

14

Stimulating Demand Among Pregnant Women and New Mothers
Table 1. mHealth interventions and strategies to stimulate the demand for MNH services among pregnant women d

mHealth Program Strategy
Intervention Main Affiliated Organizations

Information BabySMS South Africa – Subscription-based services that require
services that World of Avatar, participants to provide their expected delivery date (or date
increase women’s MTN South Africa of infant’s birth) to time content delivery for optimal impact on
awareness of users’ health knowledge and behaviors.
health issues and
encourage women SMS Appointment Philippines – Standalone services that send appointment
to use available Reminder System reminders to women who have registered at local health centers
health resources University of Philippines 2-3 days in advance of a scheduled follow-up appointment.
Medical Informatics Unit

mCheck India – Targeted services that assist women and family
World Health Organization members in the identification of crucial risk factors in mothers
PSP/CPO and newborns during the immediate week-long, high-risk
period following delivery and in seeking appropriate care.

Interactive Maternal Mexico – Interactive mapping services that mash up health

Health Mapping Tool system and geographic information system data to provide
eSAC Project; detailed information about the quality and types of maternal
Phi Research Group, health services offered in local locations.
University of Toronto; PAHO

Mobile Alliance for Bangladesh, India, South Africa – For no charge to expecting
Maternal Action (MAMA) and new mothers, MAMA offers health information in the form
USAID, Johnson & Johnson, of text messages adapted to different contexts. Messages are
babycenter developed with the help of BabyCenter, which has reached
25 million pregnant women and new mothers in 20 countries
around the world. Locally adapted messages will be available
on an online library for other projects to encourage sharing
learned lessons.

d. For a more comprehensive list of mHealth interventions and strategies, visit the database on the Health Unbound website http://www.healthunbound.org/

15

MOBILE
HEA
LTH IN MA

mHealth Program Strategy
TERN AL A ND

Patient Wired Mothers Tanzania – Services that strengthen communication between
communication University of Copenhagen; pregnant women and primary health care units through
services that Ministry of Health and Social use of mobile phones to ask questions and seek advice in
directly connect Welfare, Zanzibar, Tanzania; cases of acute or non-acute problems and potentially avoid
women to peer Health Sector Programme unnecessary visits.
networks or Support Zanzibar;
NEWBORN

expert resources Danida Health Sector
HEA

in the community Programme Support
such as skilled
LTH

birth attendants Project Kopano South Africa – Services that allow HIV-positive mothers to
The SHM Foundation, Yale communicate directly with each other via SMS about issues
School of Medicine, University affecting their lives during their pregnancy.

of Pretoria

mMitra India – Services delivered to elected, trained, trusted female
UCSF Bixby Center, ARMAAN leaders from villages’ local consultation groups to ensure that
the few eligible women without phones also have access to
the educational messages on preventive and emergency care.

Complementary Mobile for Reproductive Tanzania, Kenya – Reproductive health services that use text-
patient-support Health (m4RH) based messages to deliver evidence-based information on
services FHI 360, USAID, PROGRESS family planning methods. Services are designed to target both
addressing the men and women with information on family planning.
management of
health issues Cellphones4HIV South Africa – Programs to prevent the mother-to-child
that contribute Cell-Life, Vodacom, transmission of HIV/AIDS that use text messaging to
to maternal and USAID, PEPFAR, The Raith send educational messages and reminders for scheduled
newborn mortality Foundation, Johns Hopkins appointments, testing and treatment.
Health and Education South
Africa, Right to Care

Mobile financial Changamka Kenya – Services that enable women to save money over
services that Changamka MicroHealth Ltd. an extended period of time to gain access to primary health
remove financial care services by facilitating payment at the point of care using
barriers to care by a medical smart card combined with mobile money transfer
allowing women service systems.
to save toward
delivery and post- m-Money For Women Kenya – Services that combine mobile financial services,
natal care with Fistula educational information, and the provision of free treatment in
Fistula Care, Freedom from order to cover transport costs for women and facilitate their
Fistula Foundation, USAID, access to fistula repair services.
Vodafone Group

16

mHealth can also create
peer networks of pregnant
women or partner
first-time mothers with
experienced mothers for
support

MOBILE
HEA
LTH IN MA

mHealth services targeting new and expectant treatment for those who need it. Mothers receive
mothers involve a broad range of private and the messages free of charge and the project bears
public partnerships in the planning for promotion the cost of approximately US$1.50 per mother
TERN AL A ND

and outreach, content and format, and pricing to send messages. The intervention is still being
of mHealth services with the shared goal of evaluated as to whether they return for test results.
increasing a woman’s awareness of health issues Exit interviews indicated that participants received
and encouraging her to use health services. These a strong psychological benefit from participation.
include the use of the government health workforce A similar program among HIV-positive mothers is
(SMS Advice for Pregnant Women in Bangladesh); currently conducting an RCT to evaluate the mental
NEWBORN

facility-based posters, palm cards, and flyers health benefit from the use of mobile phones to
HEA

(Mobile for Reproductive Health in Kenya and complement standard treatment programs and the
Tanzania); and more traditional uses of national role of peer mentors who provide participants with
LTH

media campaigns (Wazazi Nipendeni in Tanzania). mental health support in managing their conditions
(Project Masihambisane in South Africa).

Preliminary evidence indicates:
• Improved compliance in scheduled follow-up In low-resource settings, a financial hurdle
appointments (SMS Appointment Reminder often confronts proper and adequate health
System in Philippines) service delivery. This is now being addressed by
• Higher rates of service utilization (Mobile transaction-based mobile financial services, which
eHealth Safe Motherhood Project in Philippines) are particularly valuable for individuals who do not
• Higher levels of trust (Mobile for Reproductive have bank accounts. Mobile technology solutions
Health in Kenya and Tanzania) that allow users to save money for future payment
• Improved user satisfaction with services for goods and services have proven particularly
(CycleTel in India) effective among expectant mothers as a sustainable
• Higher rates of delivery in the presence of financing mechanism. For example, participants
skilled birth attendants in the intervention arm can save for their antenatal, delivery, and postnatal
than the skilled birth attendant rate at delivery in services at participating health facilities. In Kenya,
Tanzania was 43 percent in 2004-20057 (Wired Changamka has distributed more than 10,000 smart
Mothers in Tanzania) cards to low-income pregnant women through
health facilities. The service is being deployed more
Results indicate the potential benefit of these broadly through other health facilities nationwide.
measures in preventing loss of mothers to follow- One example of success is the m-Money for Women
up (Cellphones4HIV in South Africa). A randomized with Fistula program, which has noted a sharp
controlled trial (RCT) in South Africa assessed the increase in caseload following the launch of a broad-
effectiveness of reminding HIV-positive mothers based outreach and promotion campaign that offers
to keep appointments, bring their infants for HIV women a free hotline, transportation, and treatment
testing, and if needed, treatment. In the trial of service. The program transfers money via M-PESA
738 mothers, more than 90% of the 323 who to those who cannot afford transport to a fistula unit.
received messages brought infants for testing, During the six months prior to the campaign, the
compared with 78% of those who didn’t receive average caseload of fistula patients at one facility
messages. The service comprises a ten-week called the Jamaa Mission Hospital (JMH) was 15 per
intervention that provides educational information month. In the month following the campaign, JMH
and reminders to keep scheduled appointments saw an increase in the demand for services as it
and bring infants for HIV testing and also further supported a patient caseload of 40 fistula patients.

18

Strengthening Human Resource
Strengthening Human Resource facilitate the ability of frontline health workers to
Capacity transmit data and receive expert feedback on urgent
Delays in accessing the appropriate level of care care cases; (2) direct communication with different
are primarily due to shortages of qualified health levels of the health system, such as in the case
professionals, most often in difficult-to-reach of emergency transportation of pregnant women
rural and remote areas. The labor shortage is with complications; and (3) tools offering improved
compounded by (1) the lack of transportation, efficiencies in remote diagnosis, treatment, and case
particularly important in emergency situations management of patients across the maternal and

Capacity
involving complications during a pregnancy, and newborn continuum of care. These efforts often
(2) the lack of systems that could support the direct information and data from the community
ability of community health workers to monitor and level to health facilities and from the district level to
track at-risk patients and to refer those in need to the Ministry of Health. Such existing programs have

specialized care in a timely manner. demonstrated their feasibility; however, success in
scaling up to the national level requires the strategic
As found in Table 2, mHealth programs strengthen alignment of the intervention with the prioritization
human resource capacity in three main ways: of MNH on national health agendas, in addition to
(1) point-of-care decision support solutions that strong public-private partnerships.

Table 2. mHealth interventions and strategies to strengthen human resource capacity for healthe

mHealth Programs Strategy

Services that ASHA (Accredited Social India – Services that provide registration forms, checklists,
support patient Health Activist) Project care protocols, and educational materials to support
tracking and CommCare community health workers in tracking pregnancies during
management at home visits, supporting maternal, neonatal and early child
the community health, and providing referrals for at-risk individuals.
level
Mobile Technology Ghana – Services that integrate community-based electronic
for Community Health records of care with the delivery of SMS or pre-recorded voice
(MoTECH) educational messages to pregnant women and their families
Grameen Foundation, to remind women and newborns that they are due for or are
Columbia University’s Mailman non-adherent with scheduled care.
School of Public Health,
Ghana Health Service

ChildCount+ Ghana, Kenya, Rwanda, Tanzania, Uganda – Services that
Millennium Villages Project allow community health extension workers to use text-
based messages to register new births, monitor community
health events in pregnant women, receive feedback on
recommended treatment, and track and manage their care.

e. For a more comprehensive list of mHealth interventions and strategies, visit the database on the Health Unbound website http://www.healthunbound.org/

19


mHealth Programs Strategy

Services that Sajida Bandhu Bangladesh – Services that support the ability of clinicians
support risk Sajida Foundation, ACCESS in central facilities to monitor data that has been collected
screening, referral, Health International and transmitted by phone during home visits and to provide
and remote medical advice in real-time.
consultation
Capacity

Mi Bebé Mexico – Mobile health monitoring services that allow health
Instituto Carlos Slim, professional and community health workers to continuously
Qualcomm and remotely monitor women with high-risk pregnancies to

provide early warning of abnormalities and to connect women
to specialized clinics in a timely manner.

Using Cell Phones for Tanzania – District-level referral services for emergency
Obstetric Emergencies obstetric care for pregnant women that connect health
Ifakara Health Institute, workers in peripheral facilities with senior medical staff
Maternal Health Task Force at district headquarters for immediate consultation and
emergency clinical support.

Services that e-IMCI (Integrated Tanzania – Services that provide electronic protocols on
provide electronic Management of mobile devices to guide health workers step-by-step through
versions of care Childhood Illness) the assessment, classification and treatment of a condition to
protocols for D-Tree International, Dimagi improve their adherence to standard care protocols as well as
community health to ensure favorable patient outcomes.
workers and
facility-based Mobiles for Quality Uganda – Education and training services that use text
staff Improvement messages to deliver daily instructions, tips, and quizzes to
Marie Stopes International, health workers that reinforce clinical content learned during
USAID training and adherence to standards and guidelines.

Clinical Patient Kenya – Services that employ portable devices with
Administration Kit embedded workflow processes that guide skilled
(CliniPAK) professionals or less skilled health workers through primary
Vecna Cares Charitable Trust, care and specialized clinical protocols and that support
Click Health improved data capture, longitudinal patient care and reporting,
and patient outreach.

Services that Capacity Project Kenya – Services that support effective communication
strengthen IntraHealth International, with health workers deployed to remote areas to improve
or improve USAID monitoring and supervision, and produce time and cost
human resource efficiencies in reporting administrative data and in responding
management to personnel concerns.
processes

20

In particular for frontline health workers, mHealth on health workers. In rural areas where paper-based
can not only improve MNH care delivery but data collection and submission to district-level
also increase work motivation, autonomy, and reporting systems requires hand delivery, traditional
supervision in a number of ways. To improve techniques are being streamlined by electronic
delivery, mobile phones offer options to better opportunities of transmission, effectively resulting
collect routine patient data during home and in both money and time savings. Furthermore,
clinic visits; screen for risk factors during data collected on mobile phones can be directed
pregnancy; transmit any data for remote review for immediate feedback by experts to frontline

Capacity
and interpretation by clinicians, which allows health workers on follow-up actions, such as
remote monitoring of high-risk pregnancies; and diagnosis, referrals, or treatment. Additionally,
deliver protocol-driven care and treatment. Mobile- administrators have the ability to track health
mediated solutions can facilitate postnatal home indicators at the community level, monitor health

visits in the period immediately following discharge worker performance, provide learning resources
from a facility, as well as provide critical linkages and to community- or facility-based health workers to
referrals to further remote monitoring or consultation. reinforce previous training or prioritize community-
level actions and resource allocation. Additionally,
With regard to increasing work motivation, well-equipped health facilities and on-time payment
autonomy, and supervision of health workers, of salaries or per diems are as important to the
mHealth solutions facilitate workloads and workforce morale as are financial incentives that
automate challenging aspects of the duties placed reward performance.

21

Transforming Health System

Transforming Health coverage of effective services at the household
System Capacity and community levels, places where delays can
The third category of mHealth efforts is aimed be reduced. Additionally, services that turn existing
at making improvements in inadequate levels of systems for monitoring and evaluation reporting
resources and poor infrastructure that limit health from paper-based into electronic or mobile-based
system capacity and performance for delivering cannot only speed up monitoring, surveillance, and
MNH services. Aforementioned examples in detection from weeks or months to real-time, but
Capacity

the previous section regarding how mHealth can also enhance accountability for health system
strengthens human resource capacity are strengthening. Since these have been described
applicable here as well. For example, services that earlier, this section will detail existing mHealth efforts
equip community-based health worker cadres that can improve the governance and introduce
with mobile tools can extend the physical space supply chain and clinical process efficiencies, as

of health facilities, which can then augment shown in Table 3.

22

Table 3. mHealth programs and strategies that strengthen health system capacity.f

mHealth Programs and Strategies
Intervention

Supply Chain • SMS for Life (Ministry of Health and Social Welfare National Malaria Control Programme,

Capacity
Management Novartis, Medicine for Malaria Venture, Swiss Agency for Development, Vodacom, PSI
Tanzania, Vodafone, IBM, Roll Back Malaria Partnership Secretariat; Tanzania) employs
mobile phone, short message service, and electronic mapping technologies to accurately
track and support review of reported weekly stock levels of artemisinin combination therapy
and quinine injectables. This information helps eliminate stock-outs and improves access to

essential medicines by allowing district-level medical officers to allocate malaria treatments
to where they are most needed, as well as coordinate emergency deliveries to health
facilities if necessary. Results of a pilot in three districts of rural Tanzania, involving 128
health facilities and covering a population of 1.2 million, reported a decline in the stock-out
rate from 26 percent of health facilities to 0.8 percent over a 21-week period. Following a
request from the Tanzanian Ministry of Health, SMS for Life has been extended to all 5,099
health facilities in Tanzania. The program is a partnership with Novartis, Vodafone Solutions
and the Roll Back Malaria initiative.
• mTrac (Uganda Ministry of Health, UNICEF, FIND; Uganda) employs text-based
messaging to track disease outbreaks and medication supplies. Community health
workers at district health centers submit weekly data reports that are sent to district-
level and national stakeholders who follow up on the outcomes; this creates a clear line
of performance accountability. The initial pilot reported a response rate of approximately
90 percent from the 170 health facilities in two districts of Uganda. The program was
transferred from the initial pilot partners FIND (Foundation for Innovative New Diagnostics)
and the Millennium Villages Project to the Ugandan government in 2011, which is now in
the process of rolling out the program nationwide through 5,000 health facilities and 8,000
community-based drug dispensaries. A key factor contributing to its success was the
incorporation of sustainability and scalability factors into the initial design and development.

Clinical Diagnostic • SMS Printers to Accelerate Return of Test Results for early infant
Results Reporting diagnosis of HIV/AIDS, SMART, (Clinton Health Access Initiative, Federal Ministry of
Health of Nigeria; Nigeria) employs SMS-driven printers that connect referral laboratories
to community clinics via Global Service for Mobile Communications (GSM) mobile networks
and a simple database application to reduce the turnaround time in laboratories returning
results of critical blood tests for HIV-exposed infants to clinics. The only consumable required
is the thermal print paper. A pilot in Nigeria that reduced the turnaround time from 33 to 14
days led to plans for the national scale-up of the project. The government is committing
financial resources to the expansion of the service. Future plans for expansion include
automating and analyzing results and adding tests for other conditions to the system. The
estimated cost for the printers is between $300 and $500 depending on suppliers.

f. For a more comprehensive list of mHealth programs and strategies, visit the database on the Health Unbound website http://www.healthunbound.org/

23


mHealth Programs and Strategies
Intervention

e-Governance • e-MAMTA (Health and Family Welfare Department, Government of Gujarat; National Rural
Health System; India) consists of an online registration system combined with a call center
to track pregnant women, infants, and children attending government-run health centers in
the state of Gujarat to improve the reliability and accuracy of state-reported data related to
Capacity

maternal and child health services and outcomes. The program ensures receipt of proper
medical services and vaccinations, and supports the identification of every pregnant mother
who visits a government health facility, and monitoring from conception through 42 days
after delivery. The call center officials frequently call the pregnant mother to ensure that
she is receiving proper medical attention. Children are monitored for a period of five years

to ensure receipt of immunizations. The Indian government has adopted the system for
replication in other states.
• mUbuzima (Rwanda Ministry of Health, Phones for Health, USAID; Rwanda) is a system
using interactive voice response through cell phones to enable community health workers
to provide in real time monthly data related to community health indicators, such as the
number of women who delivered at home or in a health facility in a given month, case
management of sick children, and nutritional and vaccination status. These data are
immediately processed, and health actors at all levels of the health system can access data
updates and plan appropriate interventions aimed at reducing maternal and child mortality
and reaching other health policy goals. The data are also used to supervise community
health workers and to provide small incentive payments based on their performance. The
Ministry of Health was able to negotiate deep discounts, which reduced the costs of airtime
by 82 percent, for SMS and voice messaging with the mobile phone operators. In the future,
it is envisioned that the system will provide decision support directly to community health
workers to enhance the delivery of maternal and child health services. mUbuzima has been
developed in collaboration with the Ministry of Health and supported by the Phones for
Health, a public-private partnership.

Professional • MDNetwork (Vodafone, MTN; Ghana and Liberia) is a free mobile phone network for
Knowledge professional doctor-to-doctor communications as a result of a partnership between MDNet,
Networks now Switchboard, and the local telecom operator, Vodafone. The service addresses a need
to share best practices and provide physicians in rural areas with expert knowledge through
peer-to-peer knowledge transfer. The launch of the service in Ghana in 2008 created the
first countrywide mobile doctor network in Africa. The program has allowed the Ghana
Medical Association to easily send bulk text messages to all physicians in Ghana, improving
countrywide emergency response capabilities and communication. Since its inception,
more than 1,900 physicians in Ghana have registered for the MDNet program and have
logged more than three million calls. In Ghana, MDNet has generated nearly $1,300,000 in
revenue for the local telecom operator Vodafone since 2008. The service was also launched
in Liberia in August 2008 and has networked 100 percent of physicians working in Liberia,
and is being introduced in Tanzania.

24

Literacy and inequities
in women’s access to
mobile phones remain
key issues in the design
and implementation of
mHealth services

Leveraging mobile technologies to promote maternal and newborn health

Leveraging mobile technologies to promote maternal and newborn health

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